Crash of a Beechcraft 350 Super King Air in Pansol: 9 killed

Date & Time: Sep 1, 2019 at 1510 LT
Operator:
Registration:
RP-C2296
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Dipolog - Manila
MSN:
FL-196
YOM:
1998
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The airplane encountered a loss of control in flight while approaching Manila and crashed into a private resort located in Barangay Pansol, Calamba, Laguna, Philippines. It lost radar contact with Manila Approach after being cleared to descent from 9,000 feet for 5,000 feet tracking-in radial 170, 25 DME to Ninoy Aquino International Airport (RPLL). The aircraft wreckage was found in a private resort with coordinates of 14°10’33.62” N and 121°11’34” E and heading approximately 228° with most its fuselage totally burned. All the nine (9) occupants were fatally injured and two (2) other persons on the ground sustained serious injuries. The aircraft took off from Dipolog Principal Airport (RPMG), Dipolog City, Zamboanga del Norte bound for Manila (RPLL) on a MEDEVAC flight. Instrument Metrological Condition (lMC) prevailed at the time of the accident.
Probable cause:
The aircraft experienced a loss of control in flight (LOC-I) after encountering adverse and hazardous atmospheric turbulent weather conditions which led to an inflight breakup.
The following contributing factors were identified:
- The presence of adverse and potentially hazardous atmospheric conditions on route of the flight.
- Failure of the flight crew to maintain situational awareness.
- Break-down of CRM to apply appropriate emergency procedures to recover the aircraft from the unusual situation they encountered.
Final Report:

Crash of a Beechcraft B200 Super King Air in Gillam

Date & Time: Apr 24, 2019 at 1823 LT
Operator:
Registration:
C-FRMV
Flight Type:
Survivors:
Yes
Schedule:
Winnipeg – Churchill – Rankin Inlet
MSN:
BB-979
YOM:
1982
Flight number:
KEW202
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1350
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
3500
Copilot / Total hours on type:
1350
Circumstances:
On 24 April 2019, the Keewatin Air LP Beechcraft B200 aircraft (registration C‑FRMV, serial number BB979), equipped to perform medical evacuation flights, was conducting an instrument flight rules positioning flight (flight KEW202), with 2 flight crew members and 2 flight nurses on board, from Winnipeg/James Armstrong Richardson International Airport, Manitoba, to Rankin Inlet Airport, Nunavut, with a stop at Churchill Airport, Manitoba. At 1814 Central Daylight Time, when the aircraft was cruising at flight level 250, the flight crew declared an emergency due to a fuel issue. The flight crew diverted to Gillam Airport, Manitoba, and initiated an emergency descent. During the descent, both engines flamed out. The flight crew attempted a forced landing on Runway 23, but the aircraft touched down on the frozen surface of Stephens Lake, 750 feet before the threshold of Runway 23. The landing gear was fully extended. The aircraft struck the rocky lake shore and travelled up the bank toward the runway area. It came to rest 190 feet before the threshold of Runway 23 at 1823:45 Central Daylight Time. None of the occupants was injured. The aircraft sustained substantial damage. The 406 MHz emergency locator transmitter activated. Emergency services responded. There was no fire.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
1. When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If procedures are not developed to instruct pilots on their roles and responsibilities during line indoctrination flights, there is a risk that flight crew members may not participate when expected, or may work independently towards different goals.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. Because emergency medical services and the fire department were not notified immediately about the declared emergency, they were not on site before the aircraft arrived at Gillam Airport.
Final Report:

Crash of a Learjet 35A in Toluca

Date & Time: Feb 7, 2019 at 0714 LT
Type of aircraft:
Operator:
Registration:
XA-DOC
Flight Type:
Survivors:
Yes
MSN:
35A-447
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the crew configured the aircraft for landing when he realized that the right main landing gear was stuck in its wheel well. The crew continued the approach and landed on runway 15. The airplane fell on its belly, causing the right wing to struck the ground. The airplane slid for few hundred metres then veered off runway to the left and came to rest in a grassy area. All nine occupants were rescued and the aircraft was damaged beyond repair.

Crash of a Beechcraft B200 Super King Air off Kake: 3 killed

Date & Time: Jan 29, 2019 at 1811 LT
Operator:
Registration:
N13LY
Flight Type:
Survivors:
No
Schedule:
Anchorage - Kake
MSN:
BB-1718
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17774
Captain / Total hours on type:
1644.00
Aircraft flight hours:
5226
Circumstances:
The pilot of the medical transport flight had been cleared by the air traffic controller for the instrument approach and told by ATC to change to the advisory frequency, which the pilot acknowledged. After crossing the initial approach fix on the RNAV approach, the airplane began a gradual descent and continued northeast towards the intermediate fix. Before reaching the intermediate fix, the airplane entered a right turn and began a rapid descent, losing about 2,575 ft of altitude in 14 seconds; radar returns were then lost. A witness at the destination airport, who was scheduled to meet the accident airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company to inquire about the overdue airplane. The following day, debris was found floating on the surface of the ocean. About 48 days later, after an extensive underwater search, the heavily fragmented wreckage was located on the ocean floor at a depth of about 500 ft. A postaccident examination of the engines revealed contact signatures consistent with the engines developing power at the time of impact and no evidence of mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination of the airframe revealed about a 10° asymmetric flap condition; however, significant impact damage was present to the flap actuator flex drive cables and flap actuators, indicating the flap actuator measurements were likely not a reliable source of preimpact flap settings. In addition, it is unlikely that a 10° asymmetric flap condition would result in a loss of control. The airplane was equipped with a total of 5 seats and 5 restraints. Of the three restraints recovered, none were buckled. The unbuckled restraints could suggest an emergency that required crewmembers to be up and moving about the cabin; however, the reason for the unbuckled restraints could not be confirmed. While the known circumstances of the accident are consistent with a loss of control event, the factual information available was limited because the wreckage in its entirety was not recovered, the CVR recording did not contain the accident flight, no non-volatile memory was recovered from the accident airplane, and no autopsy or toxicology of the pilot could be performed; therefore, the reason for the loss of control could not be determined. Due to the limited factual information that was available, without a working CVR there is little we know about this accident.
Probable cause:
A loss of control for reasons that could not be determined based on the available information.
Final Report:

Crash of a Cessna 441 Conquest II in Harmon: 3 killed

Date & Time: Nov 18, 2018 at 2240 LT
Type of aircraft:
Operator:
Registration:
N441CX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bismarck - Williston
MSN:
441-0305
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4685
Captain / Total hours on type:
70.00
Circumstances:
The pilot and two medical crewmembers were repositioning the airplane to pick up a patient for aeromedical transport. Dark night instrument meteorological conditions prevailed for the flight. Radar data showed the airplane climb to 14,000 ft mean sea level after departure and proceed direct toward the destination airport before beginning a right descending turn. The airplane subsequently broke up inflight and impacted terrain. No distress calls were received from the pilot before the accident. Although weather conditions were conducive for inflight icing, no evidence of structural icing was identified at the scene. The debris field was 2,500 ft long and the disbursement of the wreckage confirmed that both wings, the horizontal stabilizer, both elevators, and both engines separated from the airplane before impacting the ground. Examination of the wreckage revealed that the initiating failure was the failure of the wing where it passed through the center of the airplane. The three wing spars exhibited S-bending deformation, indicative of positive overload producing compressive buckling and fracture. Further, impact signatures as black paint transfers and gouged aluminum, were consistent with the left outboard wing separating when it was struck by the right engine after the wing spars failed. There was no evidence of any pre-exiting conditions that would have degraded the strength of the airplane structure at the fracture locations. Flight control continuity was confirmed. An examination of the engines, propellers, and available systems showed no mechanical malfunctions or failure that could have contributed to the accident. The descending right turn was inconsistent with the intended flight track and ATC-provided clearance. However, there was insufficient information to determine how it was initiated and when the pilot became aware of the airplane's state in the dark night IMC conditions. Yet, the
absence of a distress call or communication with ATC about the airplane's deviation suggests that the pilot was not initially aware of the change in state. The structural failure signatures on the airplane were indicative of the wings failing in positive overload, which was consistent with the pilot initiating a pullup maneuver that exceeded the airplane spars' structural integrity during an attempted recovery from the spiral dive.
Probable cause:
The pilot's failure to maintain control of the airplane in dark night conditions that resulted in an in-flight positive overload failure of the wings and the subsequent in-flight breakup of the airplane.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Presque Isle

Date & Time: Nov 22, 2017 at 1845 LT
Operator:
Registration:
N421RX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Presque Isle – Bangor
MSN:
421C-0264
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4482
Captain / Total hours on type:
3620.00
Aircraft flight hours:
7473
Circumstances:
After takeoff, the commercial pilot saw flames coming from the left engine nacelle area. He retarded the throttle and turned off the fuel boost pump; however, the fire continued. He then feathered the propeller, shut down the engine, and maneuvered the airplane below the clouds to remain in the local traffic pattern. He attempted to keep the runway environment in sight while drifting in and out of clouds. He was unable to align the airplane for landing on the departure runway, so he attempted to land on another runway. When he realized that the airspeed was decreasing and that the airplane would not reach the runway, he landed it on an adjacent grass field. After touchdown, the landing gear separated, and the airplane came to a stop. The airframe sustained substantial damage to the wings and lower fuselage. Examination of the left engine revealed evidence of a fuel leak where the fuel mixture control shaft inserted into the fuel injector body, which likely resulted in fuel leaking onto the hot turbocharger in flight and the in-flight fire. A review of recent maintenance records did not reveal any entries regarding maintenance or repair of the fuel injection system. The pilot reported clouds as low as 500 ft with rain, snow, and reduced visibility at the time of the accident, which likely reduced his ability to see the runway and maneuver the airplane to land on it.
Probable cause:
The in-flight leakage of fuel from the fuel injection system's mixture shaft onto the hot turbocharger, which resulted in an in-flight fire, and the pilot's inability to see the runway due to reduced visibility conditions and conduct a successful landing.
Final Report:

Crash of an Embraer EMB-120RT Brasília near Cuilo: 7 killed

Date & Time: Oct 12, 2017 at 1715 LT
Type of aircraft:
Operator:
Registration:
D2-FDO
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Dundo – Luanda
MSN:
120-082
YOM:
1988
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The twin engine aircraft departed Dundo Airport at 1658LT on an ambulance flight to Luanda, carrying three doctors, one patient from South Africa and three crew members. About 15 minutes into the flight, the crew reported engine problems when one of them caught fire shortly later. The airplane went out of control and crashed in an open field located near Cuilo, about 170 km southwest of Dundo. All seven occupants were killed.

Crash of a PZL-Mielec AN-28 in Mezhdurechenskoye: 5 killed

Date & Time: Oct 4, 2017 at 1853 LT
Type of aircraft:
Operator:
Registration:
UP-A2807
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Almaty - Shymkent
MSN:
1AJ007-14
YOM:
1990
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
12000
Captain / Total hours on type:
2930.00
Copilot / Total flying hours:
486
Copilot / Total hours on type:
110
Aircraft flight hours:
3631
Aircraft flight cycles:
3197
Circumstances:
The twine engine airplane departed Almaty Airport at 1835LT on an ambulance flight to Shymkent, carrying two doctors, two pilots and one flight mechanic. About 22 minutes into the flight, while cruising by night and poor weather conditions, the crew encountered an unexpected situation and was forced to shut down the right engine. Shortly later, the aircraft crashed near the village of Mezhdurechenskoye, some 28 km northwest of Almaty Airport, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all five occupants were killed.
Probable cause:
The probable cause of the accident was the shut down of the right engine and then the left engine, possibly due to a faulty shut down on part of the crew. In the course of the subsequent emergency descent due to complete loss of power of the engines with no radio communication with air traffic controllers, as well as possibly due to the resulting confusion and nervousness, the crew unintentionally forgot to switch the pressure value on the mechanical barometric altimeter of the aircraft to the pressure on the landing airfield (704 mm Hg), leaving the pressure value of 760 mm Hg, which led to incorrect readings of true altitude of the flight. Subsequently, the crew was able to start the engines and attempt to make a forced landing at a distance of 28 km from the airfield of Almaty at night in poor weather conditions in an unlit area. Incorrect readings on the barometric altimeter of the true flight altitude (the radio altimeter showed 750 m) resulted in the aircraft colliding with a power line, causing a fire, as well as colliding with the ground, as a result of which the aircraft structure completely collapsed and burned down.
Final Report:

Crash of a Swearingen SA226T Merlin IIIB in Arnprior

Date & Time: May 26, 2017
Operator:
Registration:
C-GFPX
Flight Type:
Survivors:
Yes
Schedule:
North Bay - Arnprior
MSN:
T-310
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed North Bay on an ambulance flight to Arnprior, carrying two pilots and a doctor. Following an uneventful flight, the crew was cleared for a VOR/DME approach to runway 28 under VFR conditions. On short final, the aircraft descended too low and impacted ground 50 metres short of runway. Upon impact, the nose gear collapsed and the airplane slid for about 600 metres before coming to rest. All three occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Beechcraft LR-2 Hayabusa near Assabu: 4 killed

Date & Time: May 15, 2017 at 1147 LT
Operator:
Registration:
23057
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sapporo – Hakodate
MSN:
FL-677
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The Beechcraft LR-2 Hayabusa (a version of the Beechcraft 350 Super King Air) departed Sapporo-Okadama Airport at 1123LT on a flight to Hakodate to evacuate a patient. On board were two doctors and two pilots. While descending to Hakodate at an altitude of 3,000 feet, the crew encountered poor weather conditions with low clouds and rain showers when the airplane registered 23057 (JG-3057) impacted the slope of a mountain located near Assabu, about 40 km northwest of Hakodate Airport. The aircraft disintegrated on impact and all four occupants were killed.